Burn Management

Aka: Burn Management, Thermal Burn Management, Parkland Formula for Fluid Resuscitation in Burn Injury, Consensus Formula

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II. Management: Prehospital and Home interventions for patients prior to presentation

  1. Immediately remove any items that may cause further injury
    1. Remove all clothing, jewelry, Contact Lenses
    2. Stop any ongoing burning
    3. Remove any clothing involved in scald burn
    4. Remove all clothing involved in Chemical Burn (removed with Eye Protection, gloves and other PPE)
    5. Remove all rings, belts, watches and other items that may cause Tourniquet-type effect
  2. Place the wound site under cool Running water (46 to 77 F, 8 to 25 C) for 20 minutes
    1. Indicated in all minor burn injuries or <10% BSA burn
    2. May reduce Burn Injury depth and allow for faster healing with less scar
    3. Benefits may be limited to the following one hour
  3. Do not immerse the burn in ice water (Vasoconstriction related tissue injury risk)
    1. However cool burn with water
    2. Risks further injury and Hypothermia
  4. Following wound cooling
    1. Do not break Blisters
    2. Do not apply any Topical Medications to burn site prior to evaluation
    3. Cover the wound with a clean, dry dressing
  5. Other measures
    1. Prevent Hypothermia and ease pain with nonadherent dressings
    2. Administer Analgesics

III. Management: General Pointers

  1. Use Opioids intravenously (avoid intramuscular use)
    1. Administer adequate analgesia to allow for assessment, cleaning and dressing of wounds
  2. Avoid Antibiotics until infection occurs
  3. Administer tetanus Vaccination
    1. Indicated if patient has not had at least 3 dose Primary Series AND Tetanus booster in last 5 years
    2. Tetanus Immunoglobulin indicated in dirty wound with <3 doses of Tetanus Vaccine (including Primary Series)
  4. Staff should wear Personal Protective Equipment (masks, Eye Protection, gloves) in suspected Chemical Burn
    1. Remove all clothing and jewelry from patient
    2. Precautions and Decontamination as directed by Hazard Safety Data Sheets or Poison Control
  5. Do not cover burns with Silvadene if transporting
    1. Obscures lesions for primary burn team
    2. Burn team will apply Silvadene after their evaluation
    3. Bacitracin may be applied
  6. Be Aware of edema related complications
    1. Intravenous Access loss
    2. Constricting ID bands

IV. Management: Initial

  1. Trauma Primary Survey
    1. See Airway Management in Burn Injury for Endotracheal Intubation indications
    2. Children under age 8 years (esp. under age 2 years) are more susceptible to airway edema
      1. See Advanced Airway in Children
    3. Assess airway Inhalation Injury
      1. See Smoke Inhalation
      2. Assess airway edema (intubate if suspect unstable airway)
      3. Arterial Blood Gas (ABG)
      4. Carboxyhemoglobin
        1. Hyperbaric Chamber (dive chamber) indicated for level >40
    4. Remove all clothing, jewelry, Contact Lenses
    5. Decontaminate skin of chemical contaminants (e.g. gasoline)
    6. Stop any ongoing burning
    7. Cover injured areas after evaluation to prevent overall body heat loss and assist with analgesia
      1. Extensive burns put patients at risk for Hypothermia
  2. Trauma Secondary Survey
    1. Assign Burn Injury grading and surface area involved
    2. Assess other injuries
      1. Hemodynamic instability may be due to other Traumatic Injury
    3. Evaluate for signs of intentional injury (e.g. abuse)
    4. Consider Smoke Inhalation and complications (Carbon Monoxide Poisoning, cyanide Poisoning)
    5. Evaluate for Compartment Syndrome requiring Escharotomy
      1. Escharotomy may be deferred to Trauma surgery if good doppler pulse on Ultrasound at transfer time
      2. Compartment Syndrome onset >2 hours after Burn Injury (typically 4-6 hours)
        1. Orgill (2009) J Burn Care Res 30(5): 759-68 +PMID:19692906 [PubMed]
    6. Treat acute pain (esp. with dressing changes and surgical Debridement)
      1. Intravenous Opioid Analgesics
      2. Ketamine
  3. Assess Fluid status
    1. Precaution
      1. Formulas are for general guidance
      2. Over-hydration risks ARDS
      3. Intravenous Fluids Indications by BSA burn (consider other indications in Trauma, hemodynamic factors)
        1. Child: >10% BSA burns
        2. Teens: >15% BSA burns
        3. Adults: >20% BSA burns
    2. Urine Output minimums
      1. Adult (and over 14 years old): 0.5 ml/kg per hour (typically at least 30-50 ml per hour)
      2. Child <14 years old: 1 ml/kg per hour
      3. Electrical Burns: 1 to 1.5 ml/kg per hour until urine clears
    3. Intravenous requirements for insensible loss in ADULTS (Parkland Formula, aka Consensus Formula)
      1. Indicated in age >=14 years old
      2. Parkland formula applies to burns encompassing >20% BSA
        1. First Degree Burn area does not count toward percent burn area or fluid volume
        2. Severe burns disrupt epidermal barrier and lead to large insensible fluid losses
        3. Burns >15% BSA activate SIRS response with capillary leak, Fluid Shifts and third spacing
      3. Administer 2-4 ml crystalloid (NS or LR) per kg per %BSA over 24 hours (see distribution below)
        1. Age >=14 years: 2 ml/kg per %BSA (4 ml/kg/%BSA in Electrical Burns)
        2. Lactated Ringers (LR) is preferred to avoid Hyperchloremic Metabolic Acidosis
          1. Volume requirements over first 24 hours may be as much as 10-20 Liters
        3. No initial fluid bolus is needed unless hypotensive
        4. Exercise caution in burn percentage calculation, esp. in children (overestimated by >200%)
          1. Excessive Fluid (Fluid Creep) is associated with worse outcomes (e.g. Sepsis, ARDS)
          2. Goverman (2015) J Burn Care Res 36(5): 574-9 +PMID:25407387 [PubMed]
      4. Divide rehydration over 24 hours
        1. Give 50% over first 8 hours since burn
        2. Give second 50% over next 16 hours
    4. Intravenous requirements for insensible loss in children (Cincinnati Formula, Parkland Formula)
      1. Intravenous Fluids are indicated in >10% BSA burns in children and >15% BSA burns in teens
      2. Total Fluid Volume
        1. Cincinnati Formula
          1. Give LR 4 ml/kg/%BSA PLUS 1500 ml/m2_totalBSA
        2. Parkland Formula
          1. Older children >30 kg and age <14 years: 3 ml/kg per %BSA
          2. Young children <30 kg: 4 ml/kg per %BSA
      3. Administer fluid over 24 hours
        1. Administer half in first 8 hours, and the remainder over 16 hours
      4. In younger children (<30 kg)
        1. Add 50 mEq/L Sodium Bicarbonate in first 8 hours
        2. Add 5% dextrose to fluids (and increase enteral feedings)

V. Management: Wound Care

  1. See Burn Debridement
  2. Avoid scrubbing the wound with antiseptics (e.g. Betadine, Peridex, Hibiclens)
    1. Instead, after cooling the area, wash the wound with soap and water
  3. Use sterile saline or sterile water to clean the wound and eliminate debris
    1. Burn exudates may be washed away with lukewarm tap water and bland soaps with dressing changes
  4. Blisters
    1. Blister fluid contains both Cytokines that cause inflammation, but also growth factors to speed healing
    2. Debridement of devitalized tissue should not be painful
    3. Indications to debride
      1. Debride roofs of large Blisters (>6 cm) with thin walls
        1. Allows dressings to be applied to wound directly
      2. Debride roofs of Blisters overlying joints
        1. Allows for normal joint movement
    4. Blister Debridement approach
      1. Unroof Blister with sterile scissors
      2. Clean wound with Chlorhexidine or similar mild Antibiotic soap
      3. Cover wound with ointment and nonadherent dressing
    5. Indications to NOT debride
      1. Small Blisters (<6 mm) should be left intact
      2. Large thick walled Blisters esp. palms and soles (may aspirate instead)
  5. Escaharotomy Indications
    1. Background
      1. Escharotomy incisions are performed to depth of subcutaneous fat, avoiding vital structures
      2. Typically performed by surgeons, or under their direction
      3. Goals
        1. Impoved perfusion, Sensation, motor activity, Compartment Pressures, doppler pulses
        2. Improved ventilation (chest Escharotomy)
    2. Compartment Syndrome
      1. Associated with Third Degree Burn injury to extremities (esp. circumferential burns)
      2. Escharotomy is most likely to be required in first 2-6 hours after Burn Injury
      3. Performed with lateral and medial incisions from 1 cm proximal to 1 cm distal ends of Burn Injury
    3. Chest wall burns may also require Escharotomy due to limiting respiration
      1. Performed with a vertical incision from clavicle to inferior costal margin, mid-axillary line (avoiding Breast)

VI. Management: Topical agents

  1. Avoid Topical Corticosteroids
  2. Approach
    1. Goal is to maintain clean, moist healing environment and prevent infection
    2. Dressing should allow for continued extremity function
      1. Avoid large bulky wraps
      2. Individually wrap finger wounds to allow finger range of motion
    3. Administer Analgesics 30 minutes before dressing changes
      1. Acetaminophen and Ibuprofen may be used for baseline pain
      2. Consider oral Opioid (e.g. Oxycodone 5 mg or MSIR 7.5 mg) prior to dressing change
      3. Soak adherent dressings before dressing change
    4. Method 1: Typical approach
      1. Apply topical agent (e.g. Bacitracin) to dressing (less pain than if applied directly to wound)
      2. Cover with simple dressing that is changed every 12-24 hours
        1. Nonstick Occlusive Dressing (e.g. vaseline guaze, Xeroform, adaptic)
        2. Overlying Absorptive Dressing (gauze, kerlix)
      3. Monitor for wound progression and infection
    5. Method 2: Burn center or wound care directed
      1. Apply advanced dressing (e.g. silver impregnated foam) for up to 7-14 days
      2. Ideal for larger, more sensitive burn injuries (reduces dressing change frequency)
  3. Topicals for superficial burns (first degree)
    1. No treatment needed (will heal without intervention within 1 week)
    2. Aquaphor
    3. Bacitracin ointment
    4. Sterile Medical-Grade Honey (avoid typical honey as it contains Botulism and other organisms)
      1. Cooper (2009) Wounds 21(2):29-36
        1. https://www.woundsresearch.com/content/a-comparison-between-medical-grade-honey-and-table-honeys-relation-antimicrobial-efficacy
    5. Aloe vera (may reduce pain)
    6. Topical NSAID (e.g. Diclofenac Gel, may reduce pain)
  4. Topicals for deeper burns (second and Third Degree Burns)
    1. Topical Antibiotics
      1. Bacitracin ointment
        1. Preferred initial topical agent in most cases
        2. Does not require a cover dressing (esp. useful on the face)
        3. Apply liberally to prevent drying with wound sticking to dressing (disadvantage compared with SSD)
      2. Mupirocin (Bactroban)
        1. Used for MRSA prone regions (e.g. facial burns around the nose)
      3. Mafenide acetate (Sulfamylon)
        1. Used for deep burns even if eschar present
      4. Silvadene (Silver Sulfadine, SSD)
        1. Do not apply if Transferring patient to burn center (obscures wound)
        2. Preferred in Third Degree Burns
        3. Other agents are preferred for Second Degree Burns
          1. Silvadene inhibits Keratinocyte replication and delays healing and increases scar risk
          2. Wasiak (2013) Cochrane Database Syst Rev 3:CD002106 +PMID:23543513 [PubMed]
        4. Contraindicated in Sulfa Allergy, G6PD, pregnancy and Lactation and newborns
        5. New Occlusive Dressings may offer faster healing, less pain and lower cost (e.g. Aquacel Ag)
    2. Absorptive Dressings
      1. Aquacel Ag
        1. Less pain and healing time as well as less frequent dressing changes
        2. Lower total cost than Silvadene
        3. Broad spectrum antibacterial coverage
      2. Hydrocolloid Dressings (Duoderm, urgotul)
        1. Form gel when moisture is present (absorbs exudates)
        2. Less pain and healing time
        3. However dressing has an odor and obscures visualization of the wound site
      3. Alginate Dressings
        1. Seaweed derived absorbtive dressings
    3. Nonabsorptive dressings
      1. Nonadherent gauze (e.g. Vaseline Gauze)
        1. Inexpensive dressing used for superficial burns; lacks antibacterial coverage
      2. Silicone (Mepitel)
        1. Expensive dressing that allows wound seepage to pass through to overlying bandage
      3. Silver Impregnated dressing (e.g. Acticoat)
        1. Expensive non-adherent dressing that has broad spectrum antibacterial coverage
      4. Foam Pads (e.g. Optifoam)
        1. Barrier protection of wound site
    4. Miscellaneous dressings
      1. Biocomposite or biosynthetic (e.g. Biobrane)
        1. Silicone membrane with nylon mesh
        2. Efficacy limited to superficial burns and is expensive
      2. Bioactive skin substitute (e.g. Trancyte)
        1. Expensive, but less pain and healing time and allows visualization of burn through the dressing

VII. Management: Infection

  1. Causes
    1. Staphylococcus aureus
    2. Streptococcus Pyogenes
    3. Gram Negative Bacteria (esp. Diabetes Mellitus)
      1. Pseudomonas aeruginosa
      2. Acinetobacter species
      3. Klebsiella species
  2. Precautions
    1. Signs of Iinfection may be difficult to distinguish from the original burn inflammation
    2. Infections at burn sites may progress rapidly
    3. Fever in first 72 hours of Burn Injury is typically not due to burn-related infection
      1. Often due to hypermetabolism and may be treated with antipyretics
      2. Fever after first 72 hours of Burn Injury warrants evaluation and often hospitalization
    4. Oral Antibiotic prophylaxis (e.g. Cephalexin) is NOT recommended in first or Second Degree Burns
      1. Systemic Antibiotics do not modify skin surface flora and do not reduce infection risk
      2. Systemic Antibiotics increase Antibiotic Resistance
      3. Topical Antibiotics may reduce infection risk
    5. Burn Injury in Diabetes Mellitus is associated with a high risk of infection (44%) and other complications (90%)
      1. Foot burn injuries in Diabetes Mellitus are high risk for infection (15%)
      2. Gram Negative infections are more common in Diabetes Mellitus
      3. Clinical re-examination of feet every 3-4 days is recommended (or admit for 3-4 day observation)
  3. Management
    1. Direct Antibiotics coverage to Gram Negatives and Gram Positives based on local Antibiotic Resistance

VIII. Management: Criteria for transfer or referral to burn center

  1. Partial thickness burns involving more than 10% of total body surface area
    1. Immediate transfer if partial thickness burn involving 20% BSA (10% if age under 10 or over 50 years old)
    2. Consult burn center for partial thickness burns >5% TBSA
  2. Third degree (full thickness) burns in any age group
    1. Immediate transfer if Third Degree Burn >5% of total body surface area
  3. Any burns of high risk areas
    1. Face, eyes or ears
    2. Hands or Feet
    3. Genitalia or perineum
    4. Burns over major joints
    5. Circumferential burns
  4. Electrical Burns and Lightning Injury
  5. Inhalation Injury
  6. Chemical Burns
  7. Burn Injury with associated Trauma (e.g. Fractures), in which Burn Injury is the most significant of the injuries
  8. Burn Injury expected to require >2 weeks for healing (reduce Hypertrophic Scar)
  9. Burn Injury in patients with significant comorbidity at higher risk of complication, prolonged recovery or increased mortality
  10. Inadequate analgesia despite oral Opioids
  11. Burn Injury in patients with social situation concerns
    1. Noncompliance (e.g. unable to perform home routine wound care and dressing changes)
    2. Unreliable for follow-up or unclean living conditions (e.g. homeless)
    3. Nonaccidental Trauma suspected

IX. Management: Burn-related symptoms

  1. Pruritus
    1. Skin Lubricants
    2. Cool clothes
    3. Oatmeal topical preparations
    4. Cetirizine (Zyrtec)
    5. Doxepin topically
  2. Pain
    1. Acetaminophen
    2. NSAIDs (if no Renal Injury)
    3. Opioid Analgesics
    4. Gabapentin (Neurontin) or Pregabalin (Lyrica)
  3. GI prophylaxis (Peptic Ulcer prophylaxis)
    1. Consider H2 Blocker (e.g. Ranitidine) or Proton Pump Inhibitor (PPI) for more hospitalized patients with Burn Injury

X. Management: Follow-up

  1. Burn reassessment in 24-72 hours
    1. Even initially minor appearing wounds may significantly worsen with days
    2. Superficial partial thickness burns may extend to deep partial thickness or Third Degree Burns
    3. Many burn centers have outpatient clinics open to provider referral
  2. Emergency return precautions
    1. Increasing pain (evaluate for Compartment Syndrome, infection)
    2. Increasing erythema, exudate, fever or other signs of infection
  3. Prevent reinjury to burn sites
    1. Cover with Sunscreen SPF 50 and avoid direct sunlight on Burn Injury for 2 years

XI. References

  1. (2018) ATLS, ACS, Chicago, p. 174
  2. Mason and Yowler in Herbert (2016) EM:Rap 16(4):4-5
  3. Weir (2020) Crit Dec Emerg Med 34(12): 3-11
  4. Cuttle (2009) Burns 35(6): 768-75 [PubMed]
  5. Grunwald (2008) Plast Reconstr Surg 121(5): 311e-9e [PubMed]
  6. Hettiaratchy (2004) BMJ 328(7452): 1366-8 [PubMed]
  7. Lanham (2020) Am Fam Physician 101(8): 463-70 [PubMed]
  8. Lloyd (2012) Am Fam Physician 85(1): 25-32 [PubMed]
  9. Roberts (2003) Emerg Med News 25(3): 28-31 [PubMed]
  10. Sheridan (2005) Emerg Care 21(7): 449-56 [PubMed]

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